Provider Demographics
NPI:1649364076
Name:BEVILACQUA, JOHN MICHAEL (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:BEVILACQUA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 SCHOOLHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:81 SCHOOLHOUSE RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203
Practice Address - Country:US
Practice Address - Phone:518-456-1211
Practice Address - Fax:518-452-2535
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY199635208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics